Depression may keep some men from fighting prostate cancer

NEW YORK (Reuters Health) - Depression may be source of
disparities in the treatment men get for prostate cancer,
according to a new study.

In the analysis, older men who were depressed before they
got a prostate cancer diagnosis were more likely to have
aggressive cancer, less likely to undergo the recommended
treatment for their stage and type of disease and more likely to
die.

"We traditionally think of disparities in healthcare by
race and socioeconomic status, but our research demonstrates
that mental illness can also be a significant driver of
treatment choice and outcomes in terms of prostate cancer," Dr.
Jim Hu told Reuters Health in an email.

Hu is director of robotic and minimally invasive surgery at
the David Geffen School of Medicine at UCLA. He led the new
study that was published in Journal of Clinical Oncology.

According to the Centers for Disease Control and Prevention,
almost 200,000 men were diagnosed with prostate cancer in the
U.S. in 2010, and just under 30,000 men died from the disease
that year.

Past research has linked depression to a greater likelihood
of getting less-aggressive treatment and to poorer survival in
other cancers, including breast and liver cancers. But little is
known about how depression might affect men's diagnosis and
treatment for prostate cancer, Hu and his colleagues write.

The researchers analyzed information from a large national
database of Medicare patients, focusing on more than 40,000 men
diagnosed with localized prostate cancer between 2004 and 2007
and observed through 2009.

Of those, 1,894 men were also diagnosed with depression
during the two years before their cancer was detected.

"First, we found that men with prostate cancer who were
older, lower income, with more medical (conditions), white or
Hispanic (versus Black and Asian), unmarried, residing in
nonmetropolitan areas were more likely to be depressed," Hu
said.

"In addition, depressed men were less likely to seek out
definitive therapy (surgery or radiation) in contrast to
non-depressed men," he said, which goes against the current
guidelines for treating intermediate- and high-risk disease.

After adjusting for differences in the men's tumor
characteristics and the treatment they chose, the researchers
found that depressed men had worse overall survival compared to
men who were not depressed, Hu noted.

Hu said he was surprised by the results because depressed
men were more likely to see physicians in the two years before
their prostate cancer diagnosis compared to non-depressed men -
an average of 43 times versus 27 times, respectively.

The team also found that depressed men were more likely to
get so-called expectant management, which includes the use of
hormones to decrease the aggressiveness of prostate cancer or no
treatment at all, which is called "watchful waiting" or active
surveillance.

It's possible, Hu and his colleagues write, that depression
makes men less interested in screening, leading to their cancers
being diagnosed at a later stage, and makes them choose less
aggressive treatment. The greater number of doctor visits might
be focused on mental illness, leading to less attention toward
cancer screening.

These findings cannot prove there's a cause and effect at
work, the authors caution. However, they suggest that physicians
should take care to ensure prostate cancer patients are getting
the mental health treatment they need so depression doesn't bias
a patient's treatment choices and chances for survival.

Dr. Behfar Ehdaie, a surgeon who specializes in prostate
cancer at Memorial-Sloan Kettering Cancer Center in New York,
said that mental health is an important aspect of prostate
cancer care.

Given the prevalence of depression in these men,
survivorship in that light has been underreported in the
literature, said Ehdaie, who was not involved in the study.

"We know that men who are diagnosed with prostate cancer
have an increased risk of suicide - this was shown in a Swedish
study looking at men from Sweden," he told Reuters Health.

"This adds more data from the United States, specifically
looking at men age 67 and older, that also demonstrates that
mental health should be assessed and be part of our prostate
cancer care," he said.

But Ehdaie emphasized that this study does not suggest the
less aggressive approach of expectant management is associated
with poor outcomes, or that depression increases the risk of
dying from prostate cancer.

"The endpoint evaluated is overall survival, and we do know
that from previous studies, depression is associated with
cardiovascular events, for example, which are also associated
with increased risk of mortality," Ehdaie said.

That distinction between deaths from prostate cancer or
progression of the disease, and overall deaths from any cause is
important, he added.

Ehdaie said that future studies are needed to determine the
impact of mental health issues on treatment decision making,
especially in men with intermediate- or high-risk disease who
appear not to be receiving the appropriate treatment.

"As healthcare providers, we need to be aware of the greater
risk for aggressive prostate cancer in depressed men," Hu said.
"Additionally, depressed men may require special attention in
light of the lower initiative to follow through with physician
recommendations."

Hu added that encouraging depressed men with prostate cancer
to join prostate cancer support groups may help spur them to
pursue recommended treatments.